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

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

# Introduction
Bacterial meningitis is an infection of the surface of the brain (meninges) by bacteria that have usually travelled there from mucosal surfaces via the bloodstream. In children and young people aged 3 months or older, the most frequent causes of bacterial meningitis include Neisseria meningitidis (meningococcus), Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae type b (Hib). These organisms occur normally in the upper respiratory tract and can cause invasive disease when acquired by a susceptible person. In neonates (children younger than 28 days), the most common causative organisms are Streptococcus agalactiae (group B streptococcus), Escherichia coli, S pneumoniae and Listeria monocytogenes.
Most N meningitidis colonisations are asymptomatic, but occasionally the organism invades the bloodstream to cause disease. Meningococcal disease most commonly presents as bacterial meningitis (15% of cases) or septicaemia (25% of cases), or as a combination of the 2 syndromes (60% of cases). Meningococcal disease is the leading infectious cause of death in early childhood, making its control a priority for clinical management (as well as public health surveillance and control).
The epidemiology of bacterial meningitis in the UK has changed dramatically in the past 2 decades following the introduction of vaccines to control Hib, serogroup C meningococcus and some types of pneumococcus.
This guideline does not consider meningitis associated with tuberculosis (TB), because tuberculous meningitis (or meningeal TB) is covered in the NICE guideline on tuberculosis. However, some features of the presentation of tuberculous meningitis are indistinguishable from bacterial meningitis.
Under the Health Protection (Notification) Regulations 2010, registered medical practitioners in England have a legal requirement to notify the proper officer of the local authority urgently when they have reasonable grounds for suspecting that a patient has meningitis or meningococcal septicaemia.
Where the evidence supported it, the guideline development group made separate recommendations for the management of different conditions (bacterial meningitis, meningococcal septicaemia, and in some cases, meningococcal disease). Unless otherwise specified, the recommendations refer to all children and young people aged under 16 years. The guideline development group also used the term 'neonate' in some recommendations.
The guideline will assume that prescribers will use a drug's summary of product characteristics to inform their decisions for individual patients.# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.
This guideline assumes that fever in children younger than 5 years will be managed according to the NICE guideline on fever in under 5s: assessment and initial management until bacterial meningitis or meningococcal septicaemia is suspected.
This guideline assumes that if a child presents with signs or symptoms that indicate possible infection, the infection will be managed according to the NICE guideline on sepsis: recognition, diagnosis and early management until bacterial meningitis or meningococcal septicaemia is suspected.

# Bacterial meningitis and meningococcal septicaemia in children and young people  symptoms, signs and initial assessment
Consider bacterial meningitis and meningococcal septicaemia in children and young people who present with the symptoms and signs in table 1.
Be aware that:
some children and young people will present with mostly non-specific symptoms or signs, and the conditions may be difficult to distinguish from other less important (viral) infections presenting in this way
children and young people with the more specific symptoms and signs are more likely to have bacterial meningitis or meningococcal septicaemia, and the symptoms and signs may become more severe and more specific over time.
Recognise shock (see table 1) and manage urgently in secondary care.

## Table 1 Symptoms and signs of bacterial meningitis and meningococcal septicaemia
Symptom/sign
Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria)
Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia)
Meningococcal septicaemia
Notes
Fever
Symptom or sign present
Symptom or sign present
Symptom or sign present
Not always present, especially in neonates
Vomiting or nausea
Symptom or sign present
Symptom or sign present
Symptom or sign present
Lethargy
Symptom or sign present
Symptom or sign present
Symptom or sign present
Irritable or unsettled
Symptom or sign present
Symptom or sign present
Symptom or sign present
Ill appearance
Symptom or sign present
Symptom or sign present
Symptom or sign present
Refusing food or drink
Symptom or sign present
Symptom or sign present
Symptom or sign present
Headache
Symptom or sign present
Symptom or sign present
Symptom or sign present
Muscle ache or joint pain
Symptom or sign present
Symptom or sign present
Symptom or sign present
Respiratory symptoms or signs or breathing difficulty
Symptom or sign present
Symptom or sign present
Symptom or sign present
Symptom or sign
Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria)
Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia)
Meningococcal septicaemia
Notes
Chills or shivering
Symptom or sign present
Symptom or sign present
Symptom or sign present
Diarrhoea, abdominal pain/distension
Symptom or sign present
Symptom or sign present
not known if a symptom or sign is present (not reported in the evidence)
Sore throat/coryza or other ear, nose and throat symptoms or signs
Symptom or sign present
Symptom or sign present
not known if a symptom or sign is present (not reported in the evidence)
Symptom or sign
Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria)
Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia)
Meningococcal septicaemia
Notes
Non-blanching rash
Symptom or sign present
Symptom or sign present
Symptom or sign present
Be aware that a rash may be less visible in darker skin tones  check soles of feet, palms of hands and conjunctivae
Stiff neck
Symptom or sign present
Symptom or sign present
not known if a symptom or sign is present (not reported in the evidence)
Altered mental state
Symptom or sign present
Symptom or sign present
Symptom or sign present
Includes confusion, delirium and drowsiness, and impaired consciousness
Capillary refill time more than 2 seconds
not known if a symptom or sign is present (not reported in the evidence)
Symptom or sign present
Symptom or sign present
Unusual skin colour
not known if a symptom or sign is present (not reported in the evidence)
Symptom or sign present
Symptom or sign present
Shock
Symptom or sign present
Symptom or sign present
Symptom or sign present
Hypotension
not known if a symptom or sign is present (not reported in the evidence)
Symptom or sign present
Symptom or sign present
Leg pain
not known if a symptom or sign is present (not reported in the evidence)
Symptom or sign present
Symptom or sign present
Cold hands or feet
not known if a symptom or sign is present (not reported in the evidence)
Symptom or sign present
Symptom or sign present
Back rigidity
Symptom or sign present
Symptom or sign present
not known if a symptom or sign is present (not reported in the evidence)
Bulging fontanelle
Symptom or sign present
Symptom or sign present
not known if a symptom or sign is present (not reported in the evidence)
Only relevant in children aged under 2 years
Photophobia
Symptom or sign present
Symptom or sign present
Symptom or sign not present
Kernig's sign
Symptom or sign present
Symptom or sign present
Symptom or sign not present
Brudzinski's sign
Symptom or sign present
Symptom or sign present
Symptom or sign not present
Unconsciousness
Symptom or sign present
Symptom or sign present
Symptom or sign present
Toxic or moribund state
Symptom or sign present
Symptom or sign present
Symptom or sign present
Paresis
Symptom or sign present
Symptom or sign present
Symptom or sign not present
Focal neurological deficit including cranial nerve involvement and abnormal pupils
Symptom or sign present
Symptom or sign present
Symptom or sign not present
Seizures
Symptom or sign present
Symptom or sign present
Symptom or sign not present
Capillary refill time more than 2 seconds
Unusual skin colour
Tachycardia and/or hypotension
Respiratory symptoms or breathing difficulty
Leg pain
Cold hands or feet
Toxic or moribund state
Altered mental state or decreased conscious level
Poor urine output
Be alert to the possibility of bacterial meningitis or meningococcal septicaemia when assessing children or young people with acute febrile illness.
Healthcare professionals should be aware that classical signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis. This recommendation is amended from the NICE guideline on fever in under 5s: assessment and initial management.
Be aware that children and young people with bacterial meningitis commonly present with non-specific symptoms and signs, including fever, vomiting, irritability, and upper respiratory tract symptoms. Some children with bacterial meningitis present with seizures. See table 3 in the NICE guideline on sepsis: recognition, diagnosis and early management.
Consider other non-specific features of the child's or young person's presentation, such as:
the level of parental or carer concern (particularly compared with previous illness in the child or young person or their family),
how quickly the illness is progressing and
clinical judgement of the overall severity of the illness.
In children and young people with suspected bacterial meningitis or meningococcal septicaemia, undertake and record physiological observations of heart rate, respiratory rate, oxygen saturations, blood pressure, temperature, perfusion (capillary refill) and neurological assessment (for example, the Alert, Voice, Pain, Unresponsive  scale) at least hourly.
Healthcare professionals should be trained in the recognition and management of meningococcal disease.
Notify a proper officer of the local authority urgently on suspicion of meningitis or meningococcal septicaemia. This is a legal requirement under the Health Protection (Notification) Regulations 2010.
Be aware of Public Health England's guidance on meningococcal disease.

# Pre-hospital management of suspected bacterial meningitis and meningococcal septicaemia
Primary care healthcare professionals should transfer children and young people with suspected bacterial meningitis or suspected meningococcal septicaemia to secondary care as an emergency by telephoning 999.

## Suspected bacterial meningitis without non-blanching rash
Transfer children and young people with suspected bacterial meningitis without non-blanching rash directly to secondary care without giving parenteral antibiotics.
If urgent transfer to hospital is not possible (for example, in remote locations or adverse weather conditions), administer antibiotics to children and young people with suspected bacterial meningitis.

## Suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia)
Give parenteral antibiotics (intramuscular or intravenous benzylpenicillin) at the earliest opportunity, either in primary or secondary care, but do not delay urgent transfer to hospital to give the parenteral antibiotics.
Withhold benzylpenicillin only in children and young people who have a clear history of anaphylaxis after a previous dose; a history of a rash following penicillin is not a contraindication.

# Diagnosis in secondary care
Perform a very careful examination for signs of meningitis or septicaemia in children and young people presenting with petechial rashes (see table 1).

## Investigation and management in children and young people with petechial rash
Give intravenous ceftriaxone immediately to children and young people with a petechial rash if any of the following occur at any point during the assessment (these children are at high risk of having meningococcal disease):
petechiae start to spread
the rash becomes purpuric
there are signs of bacterial meningitis (see table 1)
there are signs of meningococcal septicaemia (see table 1)
the child or young person appears ill to a healthcare professional.
If a child or young person has an unexplained petechial rash and fever (or history of fever), carry out the following investigations:
full blood count
C-reactive protein (CRP)
coagulation screen
blood culture
whole-blood polymerase chain reaction (PCR) for N meningitidis
blood glucose
blood gas.
In a child or young person with an unexplained petechial rash and fever (or history of fever) but none of the high-risk clinical manifestations (see table 1):
Treat with intravenous ceftriaxone immediately if the CRP and/or white blood cell count (especially neutrophil count) is raised, as this indicates an increased risk of having meningococcal disease.
Be aware that while a normal CRP and normal white blood cell count mean meningococcal disease is less likely, they do not rule it out. The CRP may be normal and the white blood cell count normal or low even in severe meningococcal disease.
Assess clinical progress by monitoring vital signs (respiratory rate, heart rate, blood pressure, conscious level , temperature), capillary refill time, and oxygen saturations. Carry out observations at least hourly over the next 4 to 6 hours.
If doubt remains, treat with antibiotics and admit to hospital.
If the child or young person is assessed as being at low risk of meningococcal disease and is discharged after initial observation, advise parents or carers to return to hospital if the child or young person appears ill to them.
Be aware that in children and young people who present with a non-spreading petechial rash without fever (or history of fever) who do not appear ill to a healthcare professional, meningococcal disease is unlikely, especially if the rash has been present for more than 24 hours. In such cases, consider:
-ther possible diagnoses
performing a full blood count and coagulation screen.

## Investigation and management in children and young people with suspected bacterial meningitis
In children and young people with suspected bacterial meningitis, perform a CRP and white blood cell count:
If the CRP and/or white blood cell count is raised and there is a nonspecifically abnormal cerebrospinal fluid (CSF; for example, consistent with viral meningitis), treat as bacterial meningitis.
Be aware that a normal CRP and white blood cell count does not rule out bacterial meningitis.
Regardless of the CRP and white blood cell count, if no CSF is available for examination or if the CSF findings are uninterpretable, manage as if the diagnosis of meningitis is confirmed.

## Polymerase chain reaction (PCR) tests for bacterial meningitis and meningococcal disease
Perform whole blood real-time PCR testing (ethylenediaminetetraacetic acid  sample) for N meningitidis to confirm a diagnosis of meningococcal disease.
The PCR blood sample should be taken as soon as possible because early samples are more likely to be positive.
Use PCR testing of blood samples from other hospital laboratories if available, to avoid repeating the test.
Be aware that a negative blood PCR test result for N meningitidis does not rule out meningococcal disease.
Submit CSF to the laboratory to hold for PCR testing for N meningitidis and S pneumoniae, but only perform the PCR testing if the CSF culture is negative.
Be aware that CSF samples taken up to 96 hours after admission to hospital may give useful results.

## Skin samples for meningococcal disease
Do not use any of the following techniques when investigating for possible meningococcal disease: skin scrapings, skin biopsies, petechial or purpuric lesion aspirates (obtained with a needle and syringe).

## Performing lumbar puncture and interpreting CSF parameters for suspected bacterial meningitis
Perform a lumbar puncture as a primary investigation unless this is contraindicated.
Do not allow lumbar puncture to delay the administration of parenteral antibiotics.
CSF examination should include white blood cell count and examination, total protein and glucose concentrations, gram stain and microbiological culture. A corresponding laboratory-determined blood glucose concentration should be measured.
In children and young people with suspected meningitis or suspected meningococcal disease, perform a lumbar puncture unless any of the following contraindications are present:
signs suggesting raised intracranial pressure
reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
relative bradycardia and hypertension
focal neurological signs
abnormal posture or posturing
unequal, dilated or poorly responsive pupils
papilloedema
abnormal 'doll's eye' movements
shock (see table 1)
extensive or spreading purpura
after convulsions until stabilised
coagulation abnormalities
coagulation results (if obtained) outside the normal range
platelet count below 100109/litre
receiving anticoagulant therapy
local superficial infection at the lumbar puncture site
respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency).
In children and young people with suspected bacterial meningitis, if contraindications to lumbar puncture exist at presentation, consider delaying lumbar puncture until there are no longer contraindications. Delayed lumbar puncture is especially worthwhile if there is diagnostic uncertainty or unsatisfactory clinical progress.
CSF white blood cell counts, total protein and glucose concentrations should be made available within 4 hours to support the decision regarding adjunctive steroid therapy.
Start antibiotic treatment for bacterial meningitis if the CSF white blood cell count is abnormal:
in neonates at least 20 cells/microlitre (be aware that even if fewer than 20 cells/microlitre, bacterial meningitis should still be considered if other symptoms and signs are present  see table 1)
in older children and young people more than 5 cells/microlitre or more than 1 neutrophil/microlitre, regardless of other CSF variables.
In children and young people with suspected bacterial meningitis, consider alternative diagnoses if the child or young person is significantly ill and has CSF variables within the accepted normal ranges.
Consider herpes simplex encephalitis as an alternative diagnosis.
If CSF white cell count is increased and there is a history suggesting a risk of tuberculous meningitis, evaluate for the diagnosis of tuberculous meningitis in line with the NICE guideline on tuberculosis.
Perform a repeat lumbar puncture in neonates with:
persistent or re-emergent fever
deterioration in clinical condition
new clinical findings (especially neurological findings) or
persistently abnormal inflammatory markers.
Do not perform a repeat lumbar puncture in neonates:
who are receiving the antibiotic treatment appropriate to the causative organism and are making a good clinical recovery
before stopping antibiotic therapy if they are clinically well.

## Cranial computed tomography in suspected bacterial meningitis
Use clinical assessment and not cranial computed tomography (CT), to decide whether it is safe to perform a lumbar puncture. CT is unreliable for identifying raised intracranial pressure.
If a CT scan has been performed, do not perform a lumbar puncture if the CT scan shows radiological evidence of raised intracranial pressure.
In children and young people with a reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more) or with focal neurological signs, perform a CT scan to detect alternative intracranial pathology.
Do not delay treatment to undertake a CT scan.
Clinically stabilise children and young people before CT scanning.
If performing a CT scan, consult an anaesthetist, paediatrician or intensivist.

# Management in secondary care
For recommendations on antibiotic treatment for suspected and confirmed meningitis in babies of up to and including 28 days corrected gestational age who are in neonatal units, see early- and late-onset meningitis (babies in neonatal units) in the NICE guideline on neonatal infection: antibiotics for prevention and treatment.

## Antibiotics for suspected bacterial meningitis or meningococcal disease
Treat children and young people aged 3 months or older with suspected bacterial meningitis without delay using intravenous ceftriaxone.
Treat children younger than 3 months with suspected bacterial meningitis without delay using intravenous cefotaxime plus either amoxicillin or ampicillin.
Treat suspected meningococcal disease without delay using intravenous ceftriaxone.
Treat children and young people with suspected bacterial meningitis who have recently travelled outside the UK or have had prolonged or multiple exposure to antibiotics (within the past 3 months) with vancomycin in addition to the above antibiotics.
If calcium-containing infusions are being administered, do not use ceftriaxone. Instead, use cefotaxime. See the Medicines and Healthcare products Regulatory Agency Drug Safety Update: Vol. 3 Issue 3.
In children younger than 3 months, ceftriaxone may be used as an alternative to cefotaxime (with or without ampicillin or amoxicillin), but be aware that ceftriaxone should not be used in premature babies or in babies with jaundice, hypoalbuminaemia or acidosis as it may exacerbate hyperbilirubinaemia.
If tuberculous meningitis is part of the differential diagnosis, use antibiotic treatment appropriate for tuberculous meningitis in line with the NICE guideline on tuberculosis.
If herpes simplex meningoencephalitis is part of the differential diagnosis, give appropriate antiviral treatment.

## Treatment for specific infections in confirmed bacterial meningitis
Treat H influenzae type b meningitis with intravenous ceftriaxone for 10 days in total unless directed otherwise by the results of antibiotic sensitivities.
Treat S pneumoniae meningitis with intravenous ceftriaxone for 14 days in total unless directed otherwise by the results of antibiotic sensitivities.
Treat group B streptococcal meningitis with intravenous cefotaxime for at least 14 days. If the clinical course is complicated (for example, if there is poor response to antibiotic therapy, effusion or abscess, or concomitant intraventricular haemorrhage in a premature baby), consider extending the duration of treatment and consulting an expert in paediatric infectious diseases.
Treat bacterial meningitis due to L monocytogenes with intravenous amoxicillin or ampicillin for 21 days in total, plus gentamicin for at least the first 7 days.
Treat bacterial meningitis due to gram-negative bacilli with intravenous cefotaxime for at least 21 days unless directed otherwise by the results of antibiotic sensitivities. If the clinical course is complicated (for example, if there is poor response to antibiotic therapy, effusion or abscess, or concomitant intraventricular haemorrhage in a premature baby), consider extending the duration of treatment and consulting an expert in paediatric infectious diseases.

## Treatment of unconfirmed bacterial meningitis
In children and young people aged 3 months or older with unconfirmed, uncomplicated but clinically suspected bacterial meningitis, treat with intravenous ceftriaxone for at least 10 days depending on symptoms and signs and course of the illness.
In children younger than 3 months with unconfirmed but clinically suspected bacterial meningitis, treat with cefotaxime plus either ampicillin or amoxicillin for at least 14 days. If the clinical course is complicated, (for example, if there is poor response to antibiotic therapy, effusion or abscess, or concomitant intraventricular haemorrhage in a premature baby), consider extending the duration of treatment and consulting an expert in paediatric infectious diseases.

## Meningococcal disease
In children and young people with confirmed meningococcal disease, treat with intravenous ceftriaxone for 7 days in total unless directed otherwise by the results of antibiotic sensitivities.
In children and young people with unconfirmed but clinically suspected meningococcal disease, treat with intravenous ceftriaxone for 7 days in total.

## Other aspects of management in bacterial meningitis and meningococcal septicaemia
In children and young people with suspected or confirmed meningococcal septicaemia, anticipate, monitor and correct the following metabolic disturbances using local or national protocols:
hypoglycaemia
acidosis
hypokalaemia
hypocalcaemia
hypomagnesaemia
anaemia
coagulopathy.
Use local or national protocols for management of seizures in children and young people with suspected bacterial meningitis or meningococcal septicaemia.
Use local or national protocols to treat raised intracranial pressure.
Assess for all of the following:
signs of shock (see table 1)
raised intracranial pressure
signs of dehydration.Refer to the NICE guideline on diarrhoea and vomiting caused by gastroenteritis in under 5s for assessment of shock and dehydration.
If present, correct dehydration using enteral fluids or feeds, or intravenous isotonic fluids (for example, sodium chloride 0.9% with glucose 5%, or sodium chloride 0.9% with dextrose 5%).
Do not restrict fluids unless there is evidence of:
raised intracranial pressure or
increased antidiuretic hormone secretion. See the National Patient Safety Agency's Patient safety alert 22: reducing the risk of hyponatraemia when administering intravenous infusions to children.
Give full-volume maintenance fluids to avoid hypoglycaemia and maintain electrolyte balance.
Use enteral feeds as maintenance fluid if tolerated.
If intravenous maintenance fluid is required, use isotonic fluids (for example, sodium chloride 0.9% with glucose 5%, or sodium chloride 0.9% with dextrose 5%). In neonates, use glucose 10% and added sodium chloride for maintenance.
Monitor fluid administration and urine output to ensure adequate hydration and avoid overhydration.
Monitor electrolytes and blood glucose regularly (at least daily while the child or young person is receiving intravenous fluids).
If there are signs of raised intracranial pressure or evidence of shock, initiate emergency management for these conditions and discuss ongoing fluid management with a paediatric intensivist.
In children and young people with suspected or confirmed meningococcal septicaemia:
If there are signs of shock, give an immediate fluid bolus of 10 ml/kg sodium chloride 0.9% over 5 to 10 minutes. Give the fluid intravenously or via an intraosseous route and reassess the child or young person immediately afterwards.
If the signs of shock persist, immediately give further boluses of 10 ml/kg of intravenous or intraosseous sodium chloride 0.9% or human albumin 4.5% solution over 5 to 10 minutes.
If the signs of shock still persist after the first 40 ml/kg:
immediately give another bolus of 10 ml/kg of intravenous or intraosseous sodium chloride 0.9% or human albumin 4.5% solution over 5 to 10 minutes
call for anaesthetic assistance for urgent tracheal intubation and mechanical ventilation
start treatment with vasoactive drugs
be aware that some children and young people may require large volumes of fluid over a short period of time to restore their circulating volume
consider giving further fluid boluses at 10 ml/kg of intravenous or intraosseous sodium chloride 0.9% or human albumin 4.5% solution over 5 to 10 minutes based on clinical signs and appropriate laboratory investigations including urea and electrolytes
discuss further management with a paediatric intensivist.
If shock persists despite fluid resuscitation (more than 40 ml/kg) and treatment with either intravenous adrenaline or intravenous noradrenaline, or both, consider potential reasons (such as persistent acidosis, incorrect dilution, extravasation) and discuss further management options with a paediatric intensivist.
Use local or national protocols for the administration of vasoactive agents in children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia.
In self-ventilating children and young people with signs of respiratory distress, administer 15litre face mask oxygen via a reservoir rebreathing mask.
If there is a threatened loss of airway patency, implement airway-opening manoeuvres, and start bagvalve mask ventilation in preparation for tracheal intubation.
A healthcare professional with expertise in paediatric airway management should undertake tracheal intubation.
Be aware that children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia are very ill and at grave risk of sudden deterioration during intubation. Anticipate aspiration, pulmonary oedema or worsening shock during intubation. Ensure that they are nil by mouth from admission to hospital and that the following are available before intubation:
facilities to administer fluid boluses
appropriate vasoactive drugs
access to a healthcare professional experienced in the management of critically ill children.
Undertake tracheal intubation and mechanical ventilation for the following indications:
threatened (for example, loss of gag reflex), or actual loss of airway patency
the need for any form of assisted ventilation, for example bagmask ventilation
clinical observation of increasing work of breathing
hypoventilation or apnoea
features of respiratory failure, including:
irregular respiration (for example, CheyneStokes breathing)
hypoxia (PaO2 less than 13 kPa or 97.5 mmHg) or decreased oxygen saturations in air
hypercapnia (PaCO2 greater than 6 kPa or 45 mmHg)
continuing shock following infusion of a total of 40 ml/kg of resuscitation fluid
signs of raised intracranial pressure
impaired mental status:
reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
moribund state
control of intractable seizures
need for stabilisation and management to allow brain imaging or transfer to the paediatric intensive care unit or another hospital.Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.
Use local or national protocols for intubation.

## Corticosteroids
Do not use corticosteroids in children younger than 3 months with suspected or confirmed bacterial meningitis.
Give dexamethasone (0.15 mg/kg to a maximum dose of 10 mg, 4 times daily for 4 days) for suspected or confirmed bacterial meningitis as soon as possible if lumbar puncture reveals any of the following:
frankly purulent CSF
CSF white blood cell count greater than 1,000/microlitre
raised CSF white blood cell count with protein concentration greater than 1 g/litre
bacteria on gram stain. The dosage given in the recommendation is based on high-quality evidence and is consistent with established clinical practice (see the full guideline for further details). The guideline will assume that prescribers will use a drug's SPC to inform their decisions for individual patients. Dexamethasone does not have UK marketing authorisation for use at the dose specified in the recommendation. Such use is an off-label use. Informed consent should be obtained and documented in line with normal standards in emergency care.
If tuberculous meningitis is in the differential diagnosis, refer to the NICE guideline on tuberculosis before administering steroids, because steroids may be harmful if given without antituberculous therapy.
If dexamethasone was not given before or with the first dose of antibiotics, but was indicated, try to administer the first dose within 4 hours of starting antibiotics, but do not start dexamethasone more than 12 hours after starting antibiotics.
After the first dose of dexamethasone discuss the decision to continue dexamethasone with a senior paediatrician.

## Meningococcal septicaemia
Do not treat with high-dose corticosteroids (defined as dexamethasone 0.6 mg/kg/day or an equivalent dose of other corticosteroids).
In children and young people with shock that is unresponsive to vasoactive agents, steroid replacement therapy using low-dose corticosteroids (hydrocortisone 25 mg/m2 four times daily) should be used only when directed by a paediatric intensivist. The dosage given in the recommendation is based on high-quality evidence and is consistent with established clinical practice (see the full guideline for further details). The guideline will assume that prescribers will use a drug's SPC to inform their decisions for individual patients. Dexamethasone does not have UK marketing authorisation for use at the dose specified in the recommendation. Such use is an off-label use. Informed consent should be obtained and documented in line with normal standards in emergency care.

## Adjunctive therapies
Do not use activated protein C or recombinant bacterial permeability-increasing protein in children and young people with meningococcal septicaemia.

## Monitoring for deterioration for meningococcal disease
Monitor children and young people closely after admission to hospital for signs of deterioration (monitor respiration, pulse, blood pressure, oxygen saturation and Glasgow Coma Scale score).
Be aware that children and young people with meningococcal disease can deteriorate rapidly, regardless of the results of any initial assessment of severity.

## Retrieval and transfer to tertiary care
Children and young people who need resuscitation should be discussed with a paediatric intensivist as soon as possible.
Transfer of children and young people to tertiary care should be undertaken by an experienced paediatric intensive care retrieval team comprising medical and nursing staff.

# Long-term management

## Long-term effects of bacterial meningitis and meningococcal septicaemia
Before discharging children and young people from hospital:
consider their requirements for follow-up, taking into account potential sensory, neurological, psychosocial, orthopaedic, cutaneous and renal morbidities and
discuss potential long-term effects of their condition and likely patterns of recovery with the child or young person and their parents or carers, and provide them with opportunities to discuss issues and ask questions.
Offer children and young people and their parents or carers:
information about and access to further care immediately after discharge and
contact details of patient support organisations including meningitis charities that can offer support, befriending, in-depth information, advocacy, counselling, and written information to signpost families to further help and
advice on accessing future care.
Offer a formal audiological assessment as soon as possible, preferably before discharge, within 4 weeks of being fit to test.
Offer children and young people with a severe or profound deafness an urgent assessment for cochlear implants as soon as they are fit to undergo testing (further guidance on the use of cochlear implants for severe to profound deafness can be found in the NICE technology appraisal guidance on cochlear implants for children and adults with severe to profound deafness).
Children and young people should be reviewed by a paediatrician with the results of their hearing test 4 to 6 weeks after discharge from hospital to discuss morbidities associated with their condition and offered referral to the appropriate services. The following morbidities should be specifically considered:
hearing loss (with the child or young person having undergone an urgent assessment for cochlear implants as soon as they are fit)
-rthopaedic complications (damage to bones and joints)
skin complications (including scarring from necrosis)
psychosocial problems
neurological and developmental problems
renal failure.
Inform the child's or young person's GP, health visitor and school nurse (for school-age children and young people) about their bacterial meningitis or meningococcal septicaemia.
Healthcare professionals with responsibility for monitoring the child's or young person's health should be alert to possible late-onset sensory, neurological, orthopaedic and psychosocial effects of bacterial meningitis and meningococcal septicaemia.

## Immune testing
Test children and young people for complement deficiency if they have had either:
more than 1 episode of meningococcal disease or
episode of meningococcal disease caused by serogroups other than B (for example, A, C, Y, W135, X, 29E) or
meningococcal disease caused by any serogroup and a history of other recurrent or serious bacterial infections.
Children and young people with recurrent episodes of meningococcal disease should be assessed by a specialist in infectious disease or immunology.
Do not test children and young people for complement deficiency who have had either:
a single episode of meningococcal disease caused by serogroup B meningococcus or
unconfirmed meningococcal disease.
Discuss appropriate testing for complement deficiency with local immunology laboratory staff.
If a child or young person who has had meningococcal disease has a family history of meningococcal disease or complement deficiency, test the child or young person for complement deficiency.
If a child or young person who has had meningococcal disease is found to have complement deficiency, test their parents and siblings for complement deficiency.
Refer children and young people with complement deficiency to a healthcare professional with expertise in the management of the condition.
Do not test children and young people for immunoglobulin deficiency if they have had meningococcal disease, unless they have a history suggestive of an immunodeficiency (that is, a history of serious, persistent, unusual, or recurrent infections).# Recommendations for research
The guideline development group has made the following recommendations for research. The full set of research recommendations is in the full guideline.

# Symptoms and signs of bacterial meningitis and meningococcal disease
What are the symptoms and signs of bacterial meningitis and meningococcal disease in children and young people aged under 16 years that differentiate between these conditions and minor self-limiting infections (including those characterised by fever)?

## Why this is important
Research is needed from primary and secondary care settings on the diagnostic accuracy of symptoms and signs suggestive of bacterial meningitis and meningococcal disease in children and young people. The research should focus on identifying individual symptoms and signs, or groups of symptoms and signs that are effective as predictors of bacterial meningitis and meningococcal disease. These symptoms and signs should also differentiate effectively between these conditions and minor self-limiting infections. The research should include consideration of the effectiveness of symptoms and signs of acute feverish illness as predictors of meningococcal disease. Consideration should also be given to the age of the child or young person (in terms of the relevance of particular symptoms and signs) and the clinical setting at presentation. Suitable study designs would include diagnostic accuracy studies as well as observational studies (such as casecontrol studies), and the research could include a systematic review of studies that have already been published.

# Predictive value of blood test results and CSF findings
What are the normal ranges for blood and cerebrospinal fluid (CSF) parameters in children and young people in the UK?

## Why this is important
Bacterial meningitis is a rare disease that is not easily distinguishable clinically from aseptic meningitis. It is, however, important to recognise those children who are most likely to have bacterial meningitis to direct appropriate management of the condition and to avoid inappropriate treatment of aseptic meningitis. Since the introduction of vaccines to protect against Haemophilus influenzae type b (Hib), meningococcus serogroup C and pneumococcus, no highquality studies involving previously healthy children and young people have been conducted in the UK to determine normal ranges for blood test results or CSF findings in bacterial and aseptic meningitis. Such studies are needed to provide reference values to help interpret blood test results and CSF findings in children (especially neonates) and young people with suspected bacterial meningitis.

# Albumin and crystalloid solutions for fluid resuscitation
How effective is albumin 4.5% solution compared with crystalloid saline 0.9% solution for fluid resuscitation in children and young people with septic shock?

## Why this is important
There are theoretical reasons why albumin solution may be more effective than crystalloid solution in children and young people with septic shock. However, no clinical studies have evaluated the effectiveness of albumin solution in children and young people with meningococcal disease. Concerns about the safety of colloids such as albumin solution led to a widespread change in clinical practice in the 1990s to using crystalloid solutions, despite a lack of evidence of equivalent effectiveness. Although albumin solution is considerably more expensive than crystalloid solution, a small additional benefit of albumin over crystalloid (1 death prevented in more than 14,000 treated cases) would make the use of albumin solution cost effective. Randomised controlled trials are therefore needed to compare the effectiveness of albumin and crystalloid solutions in children and young people with septic shock.

# Adjunctive corticosteroid treatment
What is the effectiveness of corticosteroids as an adjunct to antibiotic treatment in neonates with suspected or confirmed bacterial meningitis?

## Why this is important
Neonatal bacterial meningitis is associated with high morbidity, despite the availability of antibiotics that are highly effective against the leading causes of bacterial meningitis in this age group. New approaches to management are needed because there are currently no vaccines to protect against infection from the causative organisms. Corticosteroids are effective as an adjunct to antibiotic treatment in older children with meningitis caused by Hib, and in adults with bacterial meningitis. However, there is insufficient evidence to support a recommendation for adjunctive corticosteroid treatment in neonates. Extrapolation from older age groups would be inappropriate because the spectrum of organisms causing infection in neonates is different, and the impact on the developing brain of the causative organisms during inflammation may not be the same. A large-scale randomised controlled trial is therefore needed to compare the effectiveness of antibiotic treatment plus corticosteroids with antibiotic treatment alone in neonates with suspected or confirmed bacterial meningitis.

# Steroid replacement treatment
How effective is steroid replacement treatment in children and young people with vasopressor-unresponsive shock caused by septicaemia, including meningococcal septicaemia?

## Why this is important
Well-conducted but relatively small randomised controlled trials involving adults only suggest that low-dose corticosteroid replacement treatment may ameliorate haemodynamic failure and inflammatory dysregulation associated with severe sepsis. Such treatment may also improve outcomes following septic shock. Severe sepsis in children and young people differs from that in adults, in that multiple organ dysfunction is less common in children and young people, and mortality is lower. A randomised controlled trial involving children and young people is needed to evaluate the effectiveness of corticosteroid replacement treatment. Studies involving adults suggest that those with normal adrenal function have worse outcomes if they receive steroids than those with adrenal dysfunction, and so the proposed trial should consider whether testing for adrenal dysfunction before starting steroid replacement treatment improves outcomes.