Suspected bacterial meningitis in a child
Fever with altered conscious state, neck stiffness, bulging fontanelle, purpuric rash or seizures. Infants: often non-specific signs.
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PediatricsEmergency
Pediatric Bacterial Meningitis (NICE/RCH)
Pediatric Bacterial Meningitis (NICE/RCH): Suspected bacterial meningitis in a child → Assess and stabilise now → Antibiotics within 1 hour: do not dela...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Assess and stabilise now
Airway, breathing, circulation. Look for shock, purpura and signs of raised intracranial pressure.
- Infant signs: irritability, lethargy, poor feeding, apnoea, temperature instability, bulging fontanelle
- Child signs: headache, neck stiffness, photophobia, vomiting, altered conscious state (neck stiffness may be absent in infants)
- Shock: 0.9% sodium chloride 10 mL/kg IV bolus, then reassess
- Bloods: blood culture, glucose, gas with lactate, FBE, UEC (sodium), coagulation if shock or bleeding
- Treat any seizure at once (next steps)
03Warning Antibiotics within 1 hour: do not delay for LP or imaging
Give IV antibiotics within 1 hour of arrival and within 30 minutes of the decision to treat.
- If LP is unsafe or will take more than 30 minutes: give antibiotics first
- Extensive or spreading purpura: antibiotics now, no LP. Shock: antibiotics now, LP only once stable
- Do not do a CT before LP routinely; a normal CT does not exclude raised ICP
04Decision Is LP safe and possible within 30 minutes?
No if: GCS 9 or less or falling, new focal signs or seizures, posturing, abnormal pupils, bradycardia with hypertension, shock, respiratory compromise, spreading purpura, bleeding risk, or infection at the LP site. Either answer: dexamethasone and antibiotics follow.
- Raised ICP signs: GCS 9 or less or falling, new focal signs, seizures, posturing, abnormal pupils, bradycardia with hypertension
- Stabilise first: unprotected airway, respiratory compromise, shock, uncontrolled seizures, bleeding risk (coagulopathy, anticoagulant)
- Do not do LP: extensive or spreading purpura, infection at LP site
- Tachycardia or tachypnoea alone is not a contraindication
- If Yes
- Safe now
05Action LP safe: blood culture, LP now, then antibiotics at once
Only if no raised ICP signs, shock, spreading purpura or bleeding risk. Do not let LP delay antibiotics.
- CSF: cell count, protein, glucose (with blood glucose), Gram stain, culture
- Consider CSF PCR (meningococcus, pneumococcus, HSV, enterovirus, parechovirus)
- Interpret with age-specific reference values; earlier antibiotics change results
- Then give dexamethasone and antibiotics (next steps)
06Action Dexamethasone just before or with first antibiotic (not under 2 months)
Not for neonates or meningococcal septicaemia without meningitis. Age 2 to 3 months: seek infectious diseases advice.
- Child: dexamethasone 0.15 mg/kg (max 10 mg) IV 6-hourly for 4 days
- Do not delay antibiotics for it. If late: give within 4 hours, and not after 12 hours, of first antibiotic
- Stop if the organism is not pneumococcus or Hib (for example meningococcus)
07Action Age under 2 months: benzylpenicillin plus cefotaxime
Covers GBS, E. coli and Listeria. Avoid ceftriaxone under 41 weeks corrected age, with jaundice, or with calcium-containing IV fluids (including TPN). Severe beta-lactam allergy: infectious diseases advice.
- Infant: benzylpenicillin 60 mg/kg IV plus cefotaxime 50 mg/kg IV
- Under 7 days old: both 12-hourly
- 7 days to under 4 weeks: both 6- to 8-hourly
- 4 weeks to 2 months: benzylpenicillin 4-hourly, cefotaxime 6-hourly
- Neonates: see local neonatal guideline; discuss with infectious diseases
08Action Age 2 months or older: ceftriaxone; vancomycin if Gram-positive cocci or no LP
Add vancomycin if Gram-positive cocci on Gram stain, no LP before antibiotics, otitis media or sinusitis, recent beta-lactam, or pneumococcal PCR positive. Severe penicillin or cephalosporin allergy: moxifloxacin plus vancomycin, with infectious diseases advice. Do not give ceftriaxone with calcium-containing IV fluids.
- Child: ceftriaxone 100 mg/kg (max 4 g) IV daily, or 50 mg/kg (max 2 g) 12-hourly
- Or cefotaxime 50 mg/kg (max 2 g) IV 6-hourly
- Vancomycin 15 mg/kg (max first dose 750 mg) IV 6-hourly by slow infusion; dose by levels; review when organism and MICs are known
- Severe beta-lactam allergy: moxifloxacin 10 mg/kg (max 400 mg) IV daily plus vancomycin
- Listeria risk (immunocompromised): add benzylpenicillin or amoxicillin; seek infectious diseases advice
09Action Possible encephalitis or age under 4 weeks: add IV aciclovir
Give if altered conscious state, focal signs, seizures or HSV risk, and to all neonates under 4 weeks. Reduce the dose in renal impairment; keep the child well hydrated. Obese: dose on ideal body weight.
- Child 4 weeks to under 12 years: aciclovir 20 mg/kg IV 8-hourly (PCH: max 750 mg; RCH: no maximum)
- 12 years or older: aciclovir 10 mg/kg IV 8-hourly (PCH: max 750 mg; RCH: no maximum)
- Under 4 weeks: aciclovir 20 mg/kg IV 8-hourly (12-hourly if under 30 weeks gestation); discuss with infectious diseases and neonatology
- Stop only after negative CSF HSV PCR and senior review; early PCR can be falsely negative. Confirmed HSV: at least 21 days
10Action Supportive care and monitoring
Often needs high-dependency or intensive care. Serial neurological observations. Droplet precautions for the first 24 hours of antibiotics.
- Seizures: treat at once; midazolam or diazepam first line, then levetiracetam or phenytoin (see seizure guideline)
- Fluids: correct shock first; then isotonic maintenance. RCH: max 2/3 maintenance; NICE: do not restrict below maintenance. Check sodium
- Raised ICP signs or herniation risk: urgent paediatric critical care advice; osmotic agents only as a temporary measure
- Watch for SIADH, DIC (meningococcal), subdural effusion or empyema, hydrocephalus
- Fever after 4 to 6 days or no improvement at 48 to 72 hours: senior review, consider repeat LP and imaging
11Action Organism known: narrow therapy and set duration
Seek infectious diseases advice for all cases and when no organism is found.
- Duration (RCH): N. meningitidis 7 days. Treated with benzylpenicillin only: give clearance antibiotics (ask the public health unit)
- S. pneumoniae or Hib: 10 days
- GBS or Listeria: 14 to 21 days; Gram-negative bacilli: 21 days
- No organism found: at least 7 days; seek infectious diseases advice, including on dexamethasone
12Outcome Notify, prevent spread, follow up
Notify public health. Contacts of meningococcal or Hib cases: prophylaxis through the public health unit. Arrange audiology and development follow-up before discharge.
- Meningococcal and Hib: notify the public health unit at once; pneumococcal: notify within 5 days
- Close contacts of meningococcal or Hib cases: prophylaxis through the public health unit
- Audiology: test before discharge if possible (NICE: within 4 weeks of being well enough); formal test 6 to 8 weeks after discharge, earlier if concerns (RCH). Severe or profound hearing loss: urgent cochlear implant referral
- Neurodevelopmental follow-up and vaccination review
If No- Unsafe or delayed
13Action LP unsafe or delayed: blood culture, antibiotics now, LP later
Do not wait for LP or imaging. Do LP when a senior clinician decides it is safe.
- Take blood culture first if it does not delay antibiotics
- Consider blood PCR (meningococcus, pneumococcus) if LP is late
- Imaging for focal signs or raised ICP signs: antibiotics and stabilisation first
- Then give dexamethasone and antibiotics (see those steps); no Gram stain yet, so add vancomycin (age 2 months or older)
- Path rejoins step 06Shared downstream outcome
Guideline Source
NICE NG240 Meningitis (bacterial) and meningococcal disease (2024); doses: RCH Melbourne CPG Meningitis and encephalitis (Oct 2024)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Antibiotic choice and duration vary by local guideline and resistance; RCH, PCH ChAMP and NICE differ on vancomycin, durations and dexamethasone age
- Neonates under 4 weeks: follow the neonatal sepsis guideline; not for post-neurosurgical, shunt or nosocomial meningitis
- Does not cover viral, TB or fungal meningitis beyond empiric aciclovir
Contraindicated Populations
Neonates in a neonatal unit (use neonatal sepsis guideline)Post-neurosurgical, shunt-related or nosocomial meningitisAdults (use adult bacterial meningitis pathway)
Applicable Regions
AUUK
AU: Doses follow RCH Melbourne CPG (Oct 2024) and PCH ChAMP; check the local antimicrobial guideline and eTG Antibiotic.
US: IDSA 2004 adds vancomycin to empiric therapy for all children over 1 month; this pathway adds it for Gram-positive cocci, no LP, otitis media or sinusitis, recent beta-lactam or pneumococcal PCR positive (PCH ChAMP).
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Pediatric Bacterial Meningitis (NICE/RCH)?
The Pediatric Bacterial Meningitis (NICE/RCH) is a emergency clinical algorithm for Pediatrics. It provides a structured decision tree to guide clinical decision-making, based on NICE NG240 Meningitis (bacterial) and meningococcal disease (2024); doses: RCH Melbourne CPG Meningitis and encephalitis (Oct 2024).
What guideline is the Pediatric Bacterial Meningitis (NICE/RCH) based on?
This algorithm is based on NICE NG240 Meningitis (bacterial) and meningococcal disease (2024); doses: RCH Melbourne CPG Meningitis and encephalitis (Oct 2024).
What are the limitations of the Pediatric Bacterial Meningitis (NICE/RCH)?
Known limitations include: Antibiotic choice and duration vary by local guideline and resistance; RCH, PCH ChAMP and NICE differ on vancomycin, durations and dexamethasone age; Neonates under 4 weeks: follow the neonatal sepsis guideline; not for post-neurosurgical, shunt or nosocomial meningitis; Does not cover viral, TB or fungal meningitis beyond empiric aciclovir. Individual patient factors may require deviation from these recommendations.
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